Purpose: Practical nurses (PNs) rated their general and emotional
health and their employers' attention to their health and safety.
These components were examined in relationship to work setting and
intention to leave for the purpose of exploring workforce issues
involving these important care providers of frail elders.

Design/Methods: A relicensure survey mailed to all PNs in one rural
state included the Minimum Data Set for nurse workforce supply plus
questions from the Health and Retirement Survey. Data were analyzed
using Kruskal-Wallis nonparametric ANOVA, t-test, and chi-square tests.

Results: Of the state's working PNs, 813 responded, (71%) and
34% (n=269) reported nursing home employment. Overall, age and work role
were not significantly associated with self-rated general health (p=0.14
and p=0.12). Males reported poorer general (p=0.09) and emotional
(p=0.004) health. PNs working in nursing homes rated their general and
emotional health lower than PNs in other settings (p<0.001). Of the
PNs in nursing homes, 28% reported they were likely to leave their
position within one year, versus 19% in other work settings (p=0.003).
PNs with higher evaluations of their employer safety practices were less
likely to leave.

According to a recent National Nursing Home Survey (CDC, 2009)
there currently are 16,100 nursing homes in the United States with 1.7
million beds operating at an 86% occupancy rate. Moreover, with an aging
population predicted to steadily increase in the decades ahead, nursing
homes are expected to experience an increase of more than 300 percent in
the number of residents over 85 years (Administration on Aging, 2009).
The question "Who will care for the elderly?" has been raised
but has not been adequately answered (Kovner, Mezey, & Harrington,
2002). It is reasonable to predict, however, that a substantial amount
of hands-on nursing care will continue to be provided by those with more
health care training than family, but less than the most highly trained
and expensive care offered by registered nurses, advanced practice
nurses, and physicians. Specifically, practical nurses (Licensed
Practical Nurses or Licensed Vocational Nurses, depending upon the area
of the country) are a key component in providing long term care and
elder care in the US and often supervise the care provided by licensed
or certified nursing assistants (LNA or CNAs, name also area dependent).
The practical nurse has completed a non-degree nursing program (usually
less than two years) and is licensed to provide routine care.

In the last decade, the PN " hours per resident day" has
increased from 51% to 62% across all sizes of nursing homes while the
Registered Nurse (RN) "hours per resident day" has decreased
approximately 20% in medium and large facilities (Seblega, et al.,
2010). It is therefore highly likely that PNs will continue their role
in the care for the elderly, particularly in the nursing home setting
(Skillman, Andrilla, Patterson, Tieman, & Doescher, 2010). Moreover,
this trend may actually accelerate as the population ages, particularly
if RN and physician career choices don't favor work with the
elderly in nursing homes. (Cohen, 2009; Houde & Melillo, 2009; Lee,
Reuben, & Ferrell, 2005; Levy, Palat, & Kramer, 2007). While the
role of PNs is increasingly important, they have received less attention
than other segments of the nursing workforce. This study explored
PN's perceptions of their own general and emotional health, as well
as the PNs' opinion of their employers' attention to their
health and safety. These factors were analyzed in relationship to
intention to leave their position.

Aging Nursing Workforce And Nurses ' Health

There have been no studies specifically addressing PN health;
therefore, it is important to look to all segments of the nursing
workforce for cues. Nurses are an aging workforce, and recent economic
conditions may have delayed retirement for many nurses (Buerhaus,
Auerbach, & Staiger, 2009). Uncertainty about the future, coupled
with possible changes in family income and benefit package availability,
may be driving this continued labor force participation. In addition,
fewer females chose nursing careers in the 1980s and 1990s, which means
that the nurse workforce is older than ever before (Buerhaus, Staiger,
& Auerbach, 2000; Janiszewski, 2002). At the same time, assigned
work roles and organizational expectations have not evolved to recognize
the contemporary nursing workforce as knowledge workers. Nurse job
descriptions, for example, often include specific physical demands such
as, "must lift 50 pounds" even if this is not a necessary
element of the actual job. Undoubtedly, providing nursing care can be a
physically demanding job. As a case in point, one study found that
nurses on a medical surgical floor walked four to five miles on a 12
hour shift (Welton, Decker, Adam, & Zone-Smith, 2006). Yet, the
physical nature of the work doesn't not seem to create a corollary
health benefit demonstrated in weight control or other healthy behaviors
according to one hospital based study (Zapka, Lemon, Magner, & Hale,
2009). The combination of an aging workforce, the potential for delayed
retirement, the physical nature of nurses' work, and the compelling
need for the PN raises questions about the health and safety of the PN.
This is particularly true in the nursing home setting where where our
most impaired elders reside and providing care is particularly
physically demanding.

Staff caring for frail elders need to feel personally safe in order
to keep their residents safe and foster a "safety climate"
(Wisniewski, et al.). Safety initiatives for nursing home staff should
be very visible to all employees. However, in 2003, the Occupational
Safety & Health Administration (OSHA) was so concerned about the
high rate of musculoskeletal injuries in nursing home employees that
ergonomic guidelines were issued for the industry (OSHA, 2009). There is
also concern about violence towards nursing staff in long term care
settings, and there is evidence that PNs are more at risk than RNs
(Astrom, Bucht, Eisemann, Norberg, & Saveman, 2002; Gerberich, et
al., 2005; Nachreiner, et al., 2007).

In one study of nurses working in 42 large U.S. hospitals,
researchers measured the safety climate with survey questions such as
"to what extent does the nurse manager on this unit emphasizes
safety," and they found that "safety climate predicted
medication errors, nurse back injuries, urinary tract infections, (and)
patient satisfaction" (Hofman & Mark (2006). The extent to
which employers recognize employee stressors and provide perceived
support has also long been associated with productivity, reduced
absenteeism, and retention (Chang, Rosen, & Levy, 2009; Fornes,
Rocco, & Wollard, 2008). This safety climate thus becomes critically
important in the effort to maintain a stable nursing home workforce.
Evidence is clear that staff shortages and turnover in the nursing home
environment, have a detrimental effect on resident care (Bostick, Rantz,
Flesner, & Riggs, 2006; Kim, Kovner, Harrington, Greene, &
Mezey, 2009). Therefore, this study investigated a statewide workforce
of Practical Nurses with specific attention to personal characteristics
such as age, gender, work roles, and employment setting in relationship
to Practical Nurses' perceptions about personal self-health
(general and emotional) and employer practices in regards to health and
safety. The data were segmented to identify differences between PNs
working in nursing homes and those working in other settings.

The specific hypotheses tested are as follows:

1. (a) PNs' perceived general and emotional health will vary
by practice setting

3. Age, gender, work role, and practice setting will predict
PN's perception of their employer's:

(a) Safety practices

(b) Health practices

4. PNs' age, gender, perceived general health, perceived
emotional health, perceptions of employer safety practices, and
perceptions of health practices will predict their self-reported
intention to leave their principle position within 12 months.

METHODS

In January 2010, a mail survey was sent to all Vermont Licensed
Practical Nurses with their relicensure material. The survey used the
Minimum Data Set as recommended for nurse supply studies (Forum of State
Nursing Workforce Centers, 2009). Four additional questions were
included: 1. Would you say your health is excellent, very good, fair, or
poor? 2. What about your emotional health - how good you feel or how
stressed, anxious, or depressed you feel? Is it excellent, very good,
good, fair, or poor? 3. To what extent does your employer implement
practices to maximize your safety on the job? (All the time, Most of the
time, Some of the Time, Seldom, Never). 4. To what extent does your
employer implement practices to maximize your general health? (All the
time, Most of the time, Some of the Time, Seldom, Never).

The rationale for these additions was their consistency with those
on the national Health and Retirement Survey (National Institute on
Aging, 2007). Intention to leave was measured by self-report on the
following question: "How likely are you to leave your principal
position in the next twelve months?" Answer choices were on a
Likert scale, as follows: very likely, somewhat likely, somewhat
unlikely, and very unlikely. Content validity was established by a
statewide expert panel of nurses representing a variety of settings. The
study was reviewed and approved by the Institutional Review Board at the
University of Vermont and the Vermont Board of Nursing prior to
implementation.

Statistical Methods

Descriptive statistics were used to examine background variables.
For Hypothesis 1a and 1b, significant associations between health and
safety self-ratings and independent variables were determined using a
Kruskal-Wallis analysis of variance (ANOVA) on the five-point rating
scale for each health and safety question. Comparisons between levels of
significant variables were made using a Bonferroni adjusted level of
significance to account for all multiple comparisons (alpha adjusted by
the total number of cross-classifications). To address Hypotheses 2 and
3, a logistic regression model was developed using each of the four
health and safety questions (self-rated general health and emotional
health and perceived employer initiatives for safety and health) as the
dependent variables and age, gender, work role, and setting as
independent variables. The model assessed the probability of an
"excellent" self-rating versus any other response. For
Hypothesis 4, logistic regression was used with a dichotomous measure of
intention to leave ("very likely" or "somewhat
likely" versus "very unlikely" or "somewhat
unlikely") as the dependent variable and age, gender, and perceived
general health, perceived emotional health, perception of employer
safety practices, and perception of employer health practices as
independent variables. Additional analysis regarding PNs in nursing
homes also used descriptive statistics and logistic regression to
determine significant factors associated with PN's intention to
leave.

RESULTS

Eight hundred and thirteen (n=813) PNs responded to the mailed
survey (71% response rate). The majority of respondents (34%, n = 269)
were employed in nursing homes. Demographic characteristics of this
population are provided in Table 1.

The individual factors associated with PN self-rated general and
emotional health (Hypothesis 1a) are summarized in Table 2. The only
statistically significant factor associated with self-rated general
health was work setting. PNs working in a nursing homes rated their
general health significantly lower than PNs in other settings
(p<0.001). Specifically, only 16% of PNs in nursing homes rated
general health as "excellent" versus 24% of PNs in other
settings. Along with work setting, age and gender were significant
factors associated with self-rated emotional health. Nurses in the
youngest age group (<30 years) reported significantly worse emotional
health than older nurses. Males were significantly less likely to report
"excellent" or "very good" emotional health than
females (39% versus 56%). As with general health, PNs in nursing homes
reported significantly worse emotional health than PNs in other work
settings (p<0.001). Nine percent (9%) of PNs in nursing homes rated
their emotional health as "excellent" compared to 19% of PNs
in other work settings.

Factors associated with PNs perception of their employer's
health and safety practices (Hypothesis 1b) are summarized in Table 3.
Again, work setting is a significant factor in the PN's survey
response. PNs in nursing homes reported significantly lower ratings for
employer practices to promote general health and safety (p<0.001
health; p<0.001 safety).

A multivariate analysis was used to determine the factors
predicting PN's perceived general and emotional health and employer
health and safety practices (Hypotheses 2 and 3). The model compared a
rating of "excellent" on the health or safety questions versus
all other responses. The analysis confirmed that when adjusting for
other factors, employment setting was significant in predicting both
self-rated general health and emotional health (p=0.007 general health,
p=0.005 emotional health). No other factors (age, gender, or work role)
were significant in this analysis. A similar analysis was used to
determine the factors predicting PN's perception of their
employer's health and safety practices. Again, employment setting
was the only significant predictor of an "excellent" rating in
employer health practices (p<0.001) and employer safety practices
(p<0.001). Nurses in all other settings rated employer practices
significantly higher than did nurses in nursing homes.

A similar analysis determined the significant predictors for
PN's self-reported intention to leave their current nursing
position (Hypothesis 4). This analysis found that after adjusting for
age and gender, a rating of "excellent" for employer safety
practices was significant in predicting intention to leave. PNs who
rated their employer's safety practices as "excellent"
were significantly less likely to report that they were "very
likely" or "somewhat likely" to leave their current
position (p<0.001). These results are summarized in Table 4. Age and
gender were also significant predictors of intention to leave. Older PNs
and female PNs were less likely to report intention to leave (p=0.009
age; p=0.005 gender).

PNs In Nursing Homes

PNs in nursing homes reported significantly lower general and
emotional health and significantly worse perceptions of employer health
and safety practices than PNs in other work settings. In addition, PNs
in nursing homes were significantly more likely to report an intention
to leave their current position than their counterparts in other work
settings. Twenty eight percent (28%) of PNs in nursing homes reported
that they were "very likely" or "somewhat likely" to
leave their principal position in the next 12 months, versus 19% of PNs
in other work settings (p=0.003), and 16% of PNs in nursing homes
reported that they were "very dissatisfied" or "somewhat
dissatisfied" with their principal position, versus only 4% of PNs
in other work settings (p<0.0001).

Table Five provides a comparison of general demographic information
for PNs in nursing homes versus other work settings. PNs in nursing
homes had significantly fewer years experience working as a PN or in
their current position, and were significantly more likely to be
enrolled in a nursing education program.

PNs reporting "very likely" or "somewhat
likely" to leave their current position were able to provide a
reason for their response. When these reasons were collapsed into three
categories: career advancement (position change, promotion, return to
school), situational (family responsibilities, health/illness,
relocation, retirement), and job dissatisfaction (co-worker
relationship, supervisor relationship, job assignment, job stress,
management, salary/benefits), there were no significant differences in
the reason for leaving between PNs in nursing homes and those in other
work settings. About 47% of each group reported a situational reason for
leaving (p=0.749), and about 63% of each group reported a job
dissatisfaction reason (p=0.376). Respondents could choose more than one
reason for leaving.

Additional analysis was performed on only the PNs in nursing homes
to understand any significant predictors for those reporting "very
likely" or "somewhat likely" to leave. Not surprisingly,
nurses enrolled in education programs were significantly more likely to
report an intention to leave. After controlling for these individuals
the analysis found that gender, years in current position, and major
work activity were all significant in predicting intention to leave.
These results are summarized in Table 6.

Of the significant variables listed above, years in current
position was significantly different between PNs in nursing homes and
other work settings. Further analysis is recommended to determine if
intention to leave is better predicted by work setting (nursing home
versus other) or years in current position.

DISCUSSION

These data suggest that there is considerable work that must be
done to ensure that PNs in nursing homes are healthy, both physically
and mentally, and perceive there is employer support and concern
regarding their health and safety. This climate is essential for their
retention and continued ability to meet growing demand. In the future.
Hypothesis 1 was confirmed; self-rated emotional and physical health
varied by setting, with PNs in long term reporting less favorable
general and emotional health. Moreover, the youngest age cohort
perceived their emotional health less favorably, as did men. The latter
finding is at odds with many other studies that suggest that in general,
women rate their emotional health lower than men (Koopmans, et al.,
2010; Needham & Hill, 2010; Seedat, et al., 2009). This finding may
indicate that the male PNs working in the nursing home may be an
important group for further qualitative study regarding their health.

Although a directional association between employee health and
nurses' work setting cannot be ascertained within the current study
design, this study raises interesting areas of further inquiry. It is
possible, for example, that PNs with poorer perceived health self-select
to work in the nursing home setting, and these perceptions create a
cascade of outcomes. Specifically, health self-perceptions (particularly
less than optimal emotional health self-perceptions) may influence PNs
impressions of their entire work environment and role and create a less
favorable overall response from nursing home PNs. Alternately, the
nursing home may be an environment that, when compared to other PN work
settings, is less focused on health and safety. Regardless of causation,
however, these findings matter; PNs with less positive perceptions of
employer health and safety initiatives reported greater intention to
leave their position (hypothesis 4). Taken as a whole, these findings
may offer corporate administrators, facility administrators, direct
staff management, and policymakers a hopeful strategy for retention.
Perception is a powerful element in workplace and life satisfaction, and
senior level administrators clearly need to emphasize their concern for
PNs health and safety and assure that this concern is palpable
throughout the organization. Moreover, a solid launching platform is
necessary to underscore what is needed is currently in place.
Implementation of basic health and safety measures is required by law,
for example, but simply may not be recognized by PNs. Fostering
understanding of measures that have been taken may require enhanced and
ongoing communication, as well as specific, strategically placed
awareness initiatives. In addition, highlighting success, for example, a
poster declaring 12 consecutive months without a staff injury, provides
a constant visual reminder of employer values. In an early study, the
use of safety posters increased safety behavior by more than 20% (Lanier
& Sell, 1960). Other initiatives to foster a culture of safety might
include: 1) forming a management/employee team to address safety, 2)
incorporating highly visible and interactive communication and
collaboration on safety matters, 3) creating a shared vision of safety
excellence, 4) assigning critical safety functions to specific
individuals or teams, and 5) making it clear that identifying and
correcting workplace safety problems is a continuous effort (Smith,
2004). Together with training and evaluation, these actions provide
environmental prompts that underscore the value of PN's health and
safety.

Additional modest initiatives may offer substantial rewards.
Specifically, given the known and likely ongoing fiscal challenges of
the nursing home setting, a reasonable next step is an assessment of
current staff health and safety concerns followed by a systematic
assessment of organizational readiness for health/safety promotion
programming. These efforts should reflect the unique nature, challenges,
and opportunities of the nursing home setting. Fortunately, such
measurement tools exist. Faghri et al (2010), for example, used six
nursing homes to validate the Worksite Health Promotion Readiness
Checklist, therefore establishing an instrument useful for this setting.
Faghri et al also notes other, less universal instruments targeted for
specific baseline measures, which may be useful for organizations
undertaking discrete health initiatives. These include the Checklist of
Health Promotion Environments at Worksites (CHEW) (Oldenburg, Sallis,
Harris, & Owen, 2002), which is designed to access worksite
environmental features. HeartCheck (Golaszewski & Fisher, 2002),
which is focused on employer support for heart health and WorkCheck
(Golaszewski, Barr, & Pronk, 2003) which is designed to measure and
effect organizational support for employee health. These more focused
instruments are essential tools for any organization wishing to follow
The Wellness Councils of America (WELCOA) "Seven Benchmarks of
Success", given WELCOA's schematics that includes data
collection in two of the seven domains. Notably, this organizing
framework identifies administrative support as the key initial impetus
to organizational health improvement, followed by a process by which to
create community by-in. The WELCO Seven Benchmarks of Success are: 1.
Capture senior level support 2. Create a cohesive wellness team 3.
Collect data 4. Craft an operating plan 5. Choose appropriate
interventions 6. Create supportive environments and 7. Carefully
evaluate outcomes (Spyke, 2011). Clearly, although the impetus for
organizational change to optimize health and safety of employees must
start at the level of senior administration, these recommendations and
others (BLR HR and Employment Law News, 2010) reinforce the need for a
"Culture of Health" that permeates the organization, involving
all. Therefore, initiatives will only resonate with the staff if they
resonate with their own deep concerns. In that vein, it is reasonable to
look at two of the most commonly reported areas nursing workforce
trauma, back injuries and assault.

With the incidence of back injury and assault remaining stubbornly
high among healthcare employees, adoption of safe patient handling
(Waters, et al., 2006) and conflict management recommendations (Levin,
Hewitt, Misner, & Reynolds, 2003) must be a part of any safety
program in the nursing home environment. This latter study found that
even if programs addressing PN safety are in place, PN's perception
of the employer's concern is lacking. Similarly, Faghri et al,
(2010) also found that in some cases the administrator had a different
perception of health and safety offerings than nursing leadership. The
extent to which either of these align with the rank and file staff is
unknown, and variations by gender, age, ethnicity, and race have not
been fully elucidated.

Clearly, health and safety promotion in the nursing home
environment is a complex undertaking that requires resources,
commitment, constant attention, and steadfastness over time in order to
obtain tangible, sustainable results. Moreover, because safety concerns
may not be monolithic, each organization should start with an employee
assessment to determine what factors or conditions lead to perceptions
of safety gaps, and determine if these vary by age, gender,
organizational culture, and geographic location of the facility.
Concerns about the safety of the parking lot, for example, require a
very different organizational strategy than concerns about horizontal
bully activities or back injuries. Thus, identifying PN's
perceptions should be the first step toward organizing a strategic and
well received safety program. Furthermore, these individuals may become
even more important, as existing PNs exit the nursing home workplace for
retirement or opportunities in other, more positively received areas in
healthcare and demand accelerates to meet needs of aging Baby Boomers.
Nursing homes that adopt a longer planning horizon have greater
potential to retain a competitive advantage.

Finally, although health and safety initiatives that go beyond the
required protections may be costly, they are projected to have a sound
return on investment by decreased accidents and turnover. Implementation
of extensive wellness programming would thus be best enabled by state
and federal reimbursement policies that adequately reflect what is
necessary to keep a healthy and satisfied workforce caring for our
elders and others nursing homes.

At the same time, it is also important to recognize that previous
studies testing health and safety interventions have found mixed
results. In the nursing home setting, for example, Tveito and Eriksen
(2009) found no change in sick days with a nine month wellness
intervention. In contrast, other studies found that evidence for the
cost effectiveness of work-based wellness offerings (Erfurt, Foote,
& Heirich, 2006; Goetzel & Ozminkowski, 2008; Harris, Lichiello,
& Hannon, 2009; Mills, Kessler, Cooper, & Sullivan, 2007;
Pelletier, 2001). One other example (Palumbo et al, 2010), involved
registered nurses over 49 years old working in the hospital setting
attending weekly Tai Chi classes. In this randomized control design
pilot study, participants were less likely to take sick days compared to
the control group and in contrast to their own sick days from the
previous year.

The current study's findings suggest additional research is
needed to better understand the unique needs of PNs in nursing homes and
tailor effective empirically based interventions tailored to meet gender
and age cohort needs. Such efforts are difficult given the number and
complexity of the interacting factors that can contribute to a
nurse's perceptions of employer attention to health and safety on
the job, the nurses' health self-perception, and career intentions.
However, the interrelationship between physical and emotional health has
been widely acknowledged (Tosevski & Milovancevic, 2006), as has
been the relationship between health and job satisfaction. A
meta-analysis of 485 studies, for example, found job satisfaction was
most strongly associated with mental/psychological problems: burnout
(corrected r = 0.478), self esteem (r = 0.429), depression (r = 0.428),
and anxiety (r = 0.420). The correlation with subjective physical
illness was more modest (r = 0.287) (Faragher, et al., 2005). The extent
to which the PNs in nursing homes mirror other populations is unknown.
Thus, the current study offers a modest beginning toward understanding a
population largely ignored in previous studies, yet critical to the care
of the nation's infirm elders.

This study was limited by its setting, one rural US state that
lacks substantial ethnic diversity. Moreover, the use of the relicensure
process through the State Board of Nursing raised some limitations in
instrumentation, as only questions approved by the Board were included.
Despite these limitations, this study offers an analysis of a
substantial proportion of these key caregivers in an entire US state.
Moreover, the State does offer considerable diversity in social class
and income. These factors, along with its small size, make it an
important research laboratory. Further studies of PNs in other
geographic regions are warranted for the purpose generating
evidence-based practice intervention to improve health and safety of
this important caregiving population. Specific interventions should be
tested in studies that are designed with experimental control.

BLR HR and Employment Law News. (2010). Get employees engaged in
wellness by creating a strong 'culture of health'. Retrieved
from http://hr.blr.com/HR-news/BenefitsLeave/Employee-Wellness/Get-Employees- Engaged-in-Wellness-By-Creating-Stro/

OSHA. (2009). Guidelines for nursing homes: ergonomics for the
prevention of musculoskeletal disorders. US Department of Labor.
Retrieved from http://www.osha.gov/ergonomics/guidelines/nursinghome/
finalnhguidelines.pdf